Women’s Center for Cosmetic and Plastic Surgery

PATIENT INFORMATION

NAME: ______DATE:______

HOW DO YOU PREFER TO BE ADDRESSED? ______

HOME #:______MAY WE LEAVE A MESSAGE AT HOME? ______

WORK #:______MAY WE LEAVE A MESSAGE AT WORK? ______

CELL #:______MAY WE LEAVE A MESSAGE ON CELL? ______

EMAIL ______MAY WE CONTACT YOU BY EMAIL? ______

HOME ADDRESS: ______APT______

CITY: ______ST:______ZIP:______MARITAL STATUS: S M D W

DATE OF BIRTH:______AGE:_____SEX:____ S.S. #______

OCCUPATION: ______EMPLOYER: ______

BUSINESS ADDRESS: ______

SPOUSE: ______WORK PHONE: ______

OR

PARENT: ______WORK PHONE: ______

PARENT EMPLOYER & ADDRESS: ______

EMERGENCY CONTACT PERSON:______PHONE: ______

NAME/ADDRESS/PHONE OF YOUR PRIMARY PHYSICIAN:______

______

Who referred you to our office?______May we thank them? Yes_____ No_____

PRIMARY INSURANCE: ______INSURED: ______

POLICY #: ______GROUP #: ______

INSURANCE ADDRESS AND PHONE: ______

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HEALTH DATA SHEET

NAME: ______DATE OF BIRTH______

SURGICAL PROCEDURES YOU WOULD LIKE TODISCUSS: ______

IS YOUR GENERAL HEALTH GOOD? YES_____ NO_____DATE OF LAST EXAM______

LIST ALL MEDICATIONS (Including over the counter medications or supplements) ______

______

LIST ALL DRUG ALLERGIES OR ADVERSE DRUG ALLERGIES:

______

DO YOU SMOKE?YES_____NO_____IF SO, HOW MUCH?______

DO YOU DRINK ALCOHOL?YES_____NO_____IF SO, HOW MUCH?______

HAVE YOU HAD ANY OPERATIONS OR BEEN HOSPITALIZED FOR ANY REASON? YES_____ NO_____

PLEASE LIST DATES AND REASONS: ______

______

DO YOU HAVE ANY OF THE FOLLOWING MEDICAL PROBLEMS?

Y N HIGH BLOOD PRESSURE Y N RHEUMATIC FEVER Y N EYE DISEASE

Y N ANKLE SWELLING Y N HEART TROUBLE Y N DRYNESS OF EYES

Y N EXCESS BLEEDING Y N HEART MURMUR Y N EXCESSIVE TEARING

Y N BLOOD DISORDERS Y N PALPITATIONS Y N ITCHY EYES

Y N DIABETES Y N IRREGULAR HEARTBEAT Y N CHRONIC SINUS PROBLEM

Y N HEPATITIS Y N CHRONIC LUNG DISEASE Y N CHRONIC FEVER

Y N CANCER Y N SHORTNESS OF BREATH Y N EPILEPSY

Y N THYROID PROBLEMS Y N CHRONIC BRONCHIAL DISEASE Y N PSYCHIATRIC PROBLEMS

Y N KIDNEY PROBLEMS Y N ASTHMA Y N NERVOUS BREAKDOWN

Y N CHEST PAIN Y N PROBLEMS WITH SCARRING Y N ANEMIA

Y N JOINT PAIN Y N KELOID FORMATION Y N SCLERODERMA

Y N CHRONIC FATIGUE Y N EXCESSIVE BRUISING Y N LUPUS

Y N JOINT SWELLING Y N CHRONIC SKIN PROBLEMS Y N FACIAL HERPES/COLDSORES

PLEASE LIST ANY CONDITION OR ILLNESSES YOU HAVE WHICH ARE NOT LISTED ABOVE:______

______

PLEASE LIST ANY DISEASES OR ILLNESSES WHICH RUN IN YOUR FAMILY:

PATIENT BREAST HISTORY QUESTIONNAIRE

(This form for Breast Procedure Patients Only)

PATIENT NAME: ______

REASON FOR EVALUATION: ______

______

DO YOU PERFORM BREAST SELF-EXAMINATION?YES_____NO______HOW OFTEN?______

DO YOU HAVE LUMPS IN YOUR BREAST NOW? YES_____NO_____

IF YES, HOW WERE THEY DISCOVERED? ______

WHERE ARE THEY LOCATED?______

WHEN WERE THEY DISCOVERED? ______

HAVE YOU HAD A MAMMOGRAM? YES_____NO_____ IF YES, WHERE?______DATE(S) ______

WHAT DID THE MAMMOGRAM SHOW? ______

DO YOU HAVE A NIPPLE DISCHARGE?YES_____NO_____ LEFT______RIGHT_____

HOW LONG?______

COLOR OF DISCHARGE?______

DO YOU HAVE BREAST DISCOMFORT, PAIN OR SORENESS?YES_____ NO_____ LEFT______RIGHT_____

HOW LONG?______

HAVE YOU HAD AN INJURY TO YOUR BREAST?YES_____ NO_____ LEFT______RIGHT_____

WHEN AND HOW? ______

HAVE YOU HAD PREVIOUS BREAST SURGERY?

BIOPSYYES_____NO_____DATE(S)______

BREAST LIFTYES_____NO_____DATE(S)______

BREAST REDUCTIONYES_____NO_____DATE(S)______

LUMPECTOMYYES_____NO_____DATE(S)______

MASTECTOMYYES_____NO_____DATE(S)______

BREAST IMPLANTSYES_____NO_____DATE(S)______

REVISIONAL

IMPLANT SURGERYYES_____NO_____DATE(S)______

IMPLANT SIZE:______TYPE______SALINE / SILICONE

IMPLANT MANUFACTURER:______

FAMILY HISTORY OF BREAST CANCER?YES_____NO_____

Self_____ Grandmother_____ Mother______Sister_____ Aunt_____ Daughter_____ Other_____

FAMILY HISTORY OF FIBROCYSTIC DISEASE OR OTHER BENIGN CONDITION?YES_____ NO_____

Self_____ Grandmother_____ Mother______Sister_____ Aunt_____ Daughter_____ Other_____

NUMBER OF PREGNANCIES? ______NUMBER OF LIVE BIRTHS?______

YOUR AGE AT FIRST PREGNANCY? ______YOUR AGE AT LAST PREGNANCY? ______

DID YOU BREASTFEED CHILDREN? ______HOW MANY?______HOWLONG EACH?______

PATIENT AUTHORIZATION

INSURANCE ASSIGNMENT

In consideration of services rendered or to be rendered, I hereby assign and transfer to Diane L. Gibby, M.D., any benefits payable to or for my benefit under hospitalization or sickness insurance, and any other insurance coverage, to include major medical for the payment of such services rendered. I agree to cooperate, aid, and assist Diane L. Gibby, M.D., in procuring all possible insurance benefits including initiation and fulfillment of all policy provisions such insurance may require for payment.

This assignment of benefits is irrevocable and extends to the total amount owed to Diane L. Gibby, M.D. A photocopy of this assignment of benefits is to be considered as valid as the original.

INITIAL:______

FINANCIAL RESPONSIBILITY

I understand that regardless of my insurance benefits, I AM RESPONSIBLE FOR THE TOTAL CHARGES FOR SERVICES RENDERED, and I further agree that ALL AMOUNTS ARE DUE UPON REQUEST and are payable to Diane L. Gibby, M.D.

I further understand that should this account become delinquent and it becomes necessary for the account to be referred to an attorney or collection agency for collection or suit, I , as the designated responsible party, shall pay the reasonable attorney fees and collection expense.

INITIAL:______

RELEASE OF INFORMATION

I authorize Diane L. Gibby, M.D., to release any medical information requested by representatives of local, state, or federal agencies, insurance companies, or other organizations or entities as may be required by said representatives for payment of claims arising out of these medical services as are due to Diane L. Gibby, M.D.

INITIAL:______

PHOTOGRAPH RELEASE

I authorize the use of all photographs taken of me for any medical purpose deemed appropriate by my physician. I authorize the release of pre- and postoperative photographs to referring physicians.

INITIAL:______

Thank you for understanding our Financial Policy. Please let us know if you have any questions or concerns.

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DateSignature of Responsible Party

ABOUT FINANCIAL ARRANGEMENTS AND INSURANCE

We will gladly discuss your proposed treatment and answer any questions relating to your insurance. However, your insurance is a contract between you, your employer and the insurance company. We are not a party to that contract. Dr. Gibby is not a provider for any insurance companies, so please be aware that some and perhaps all of the services provided may be “non-covered” services and not considered medically necessary by your insurance provider. Insurance companies reimburse on a fee schedule, which may bear no relationship to the current standard and cost of care in this area. Because Dr. Gibby is out-of-network for your insurance company, your reimbursement for covered procedures may be considerably less than a physician within your network.

Dr. Gibby and staff strive to provide the best treatment possible for all patients. All fees are due and payable at time of service or in the case of elective surgical procedures, prior to this service being provided.

Please be aware that insurance companies reimburse on a fee schedule, which may bear no relationship to the current standard and cost of care in this area. Because Dr. Gibby is out-of-network for your insurance company, your reimbursement for covered procedures may be considerably less than a physician within your network.

OFFICE VISITS

Full payment is due at the time of services. We accept cash, check, Money Order, Visa, MasterCard, American Express and Discover. The fee for your new-patient consultation is complimentary.

FINANCING OPTIONS

To find the best loan, we have researched several options for you. These financing programs are not managed or administered by The Women's Center for Cosmetic and Plastic Surgery or Dr. Gibby. Any agreement reached is solely between the lending institution and the patient. An administrative fee is assessed for processing the application.

SURGICAL PROCEDURES

Writing a letter to request pre-determination and filing the claim is a courtesy we extend to our patients. WE DO REQUIRE THE TOTAL BILL BE PAID 10 DAYS PRIOR TO SURGERY. We will be happy to work with you and your insurance company; however, all charges are your responsibility from the date services are rendered and payable in full.

COSMETIC SURGICAL PROCEDURES

All cosmetic procedures must be pre-paid by CASHIER’S CHECK, MASTERCARD, VISA, AMERICAN EXPRESS, DISCOVER or MONEY ORDER 10 days prior to surgery. If you charge a cosmetic procedure on your credit card and cancel but do not reschedule your surgery, a refund will be given except for the 3% finance charge and the $500 nonrefundable deposit. If you cancel your surgery on the day of surgery, the facility fee is nonrefundable and there is a 20% cancellation fee on the surgical and anesthesiologist fee. If you choose one of the finance options, there is a $150 administrative fee added to the total cost of surgery. MedicalCityDallasHospital does not participate in outpatient finance programs.

QUESTIONS

We believe it is important that our patients fully understand our financial policy before surgery so that we can better serve you and avoid any problems postoperatively concerning this matter. We welcome any questions you may have.

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Signature of Patient or Responsible Party Date

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